Vaginismus

Vaginismus is a condition in which a woman's vaginal muscles tense up involuntarily, whenever any approach is made to her sex organs.

This spasm is often so painful that intercourse is impossible – sometimes for years. It's a common sexual difficulty and may even provoke a marriage break-up.

The contraction can also happen whenever a nurse or doctor tries to do a vaginal examination on the woman or even examine the lower part of her body. And it usually prevents her from touching or exploring her own lower abdomen.

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Typically, women with vaginismus may find it impossible to insert or wear tampons.

Indeed, the fact that they often react with a shudder when the words 'Tampax' or 'Lillets' are mentioned is referred to by us as 'the tampon test' for vaginismus.

Difficulties caused by vaginismus

There are three consequences of vaginismus.

Firstly, it's almost impossible for the woman to have a successful sexual relationship because whenever a would-be sexual partner (whether male or female) tries to become intimate or stimulate her, then her body is likely to roll up into a tight ball.

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If the partner does attempt penetration, he or she will find that the woman's vagina has closed down, like a mouth saying: 'No'. The tightness is caused by involuntary contractions of the pelvic floor muscles surrounding the vagina.

In many cases, penetration may be difficult or completely impossible. Any attempt at putting a finger or a penis inside the vagina will cause pain, burning or stinging because the muscles are in a tight spasm. Also, there will probably be no lubrication, so if entry does occur everything will be dry, and this can cause pain and discomfort.

But perhaps surprisingly, some women who have vaginismus are interested in sex and would like to have intercourse with their partners.

A few of them can reach orgasm – though this isn't easy because of the difficulty in getting access to the area of the clitoris.

Secondly, vaginismus does make it problematical for the woman to achieve good-quality healthcare. This is because she'll find it almost impossible to have a gynaecological examination.

Therefore, the medical records for women with vaginismus are likely to show that they have never had a smear test in their lives. Again and again, the clinical notes say: 'Not available for smear test today because she's on her period'.

In many cases this doesn't matter too much because the patient is probably a virgin, and so she's unlikely to get cervical cancer – which is what the smear test (Pap smear) is intended to protect against.

But if the woman does develop some gynaecological condition, her vaginismus will make it difficult to examine her.

In such cases, she may have to go into hospital for the procedure known as: 'examination under anaesthetic (EUA)' – where she can be examined while fully asleep, and she'll be relaxed.

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Thirdly, the woman can only use sanitary towels during her periods, because using tampons is likely to be very nearly impossible for her.

Why does vaginismus occur?

Vaginismus is a condition that causes woman immense distress, and it can often affect her relationships. It's by far the most common cause of unconsummated marriages. A few women with vaginismus have been married and divorced several times.

Why does it occur?

Because this is a psychological condition, the origins of the disorder lie in the mind.

But I cannot stress strongly enough that this disorder is NOT the woman's fault. She hasn't intentionally 'caused' or directed her body to tighten and cannot simply make it stop.

There are two types of vaginismus.

Primary vaginismus occurs when the condition has always been present and a woman has never at any time been able to have pain-free intercourse due to vaginismus tightness.

Secondary vaginismus can affect women at a later stage in all stages of life. This is less common.

Primary vaginismus

Most women with vaginismus have had a restrictive upbringing, where they got various false impressions – usually from their parents – about sex and the vagina.

These unfortunate and mistaken beliefs may include the following:

sex is agonisingly painful

sex is dirty

the female vagina is small and narrow

anything that's put into the vagina will cause terrible distress and injury.

Although these views are less common than they used to be, they're still surprisingly common among schoolgirls and young women, particularly in certain cultures.

Unfortunately, such notions may still be 'reinforced' by ill-informed doctors, who encounter a patient with vaginismus and promptly tell her that she's 'small-made' – therefore falsely confirming her worst suspicions.

Alternatively, the doctor may mistakenly tell her that she has 'a thick hymen' and this is the reason for all the pain and difficulty in penetration.

In fairness, there are occasional instances where a young woman does have a tough hymen or some other obstacle to penetration, such as a 'septum' (a wall) separating the two halves of a bifid (double) vagina.

The usual result of vaginismus is that the woman goes through life trying to form relationships and perhaps even getting married – in which case she is likely to remain one of the well-known 'virgin wives'.

Or maybe she can manage sex occasionally, despite the pain.

It's worth noting that in a few cases, the male becomes impotent (or partially so) – as a result of all the stress and trauma of the marital situation.

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Secondary vaginismus

This is less common, and it occurs in women who have had some distressing vaginal injury, or who have been raped or sexually assaulted.

This type of traumatic experience is likely to make the woman develop vaginismus as a protective reaction.

Occasionally, vaginismus occurs secondarily to having some painful gynaecological condition – such as endometriosis or postmenopausal vaginitis.

It can also be triggered by medical conditions, an episiotomy, an obstetric tear, traumatic events, relationship issues, surgery, or disorders of the menopause. Sometimes women develop it after a period of severe illness, such as cancer.

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So, in many cases, these woman who have had many years of pain-free intercourse will have developed a conditioned response resulting in ongoing, involuntary vaginal tightness with attempts at intercourse.

Treatment of vaginismus

Fortunately, vaginismus can be treated and cured.

I have seen many women who have managed to defeat this condition completely, usually with the aid of a sympathetic woman doctor.

Vaginal dilators

For women with penetration difficulties or pain, there's a therapy – which has been promoted by many gynaecologists – that involves teaching patients to use 'graduated vaginal dilators'.

These are little rods, which are a few inches long and range in thickness from pencil-slimness to approximately the girth of a slim penis.

A woman can begin by getting used to inserting the one with the smallest diameter into her, and then gradually work up, over a period of months, to the largest one.

This procedure often works quite well, though actually the 'dilators' are not really 'dilating' (widening) her. But they're helping her to relax and get used to the idea of something inside her vagina. NHS dilators tend to be a bit hard, blunt and unyielding. But in 2016, we encountered a new idea: silicone vaginal vibrators. These are soft, flexible, taper-tipped and comfortable to use. If you wish, you can pop a small vibrator inside them. For some women, this would make them more agreeable to use. They are available (for about £49 a set) from Sh! – the women's sex emporium. Very sensibly, the suppliers advise that you check with your doctor, nurse or therapist before using the devices.

Masters and Johnson therapy

From the late 1960s onwards, the American sex researchers Masters and Johnson became successful in pioneering their famous 'sensate focus' therapy.

If I may attempt to simplify a complex process: the general idea was that the couple came and stayed together at a residential clinic, where they were asked to make no attempt at intercourse at all.

But instead, they were asked to have regular daily sessions in which they relaxed as much as possible and concentrated on cuddling and stroking each other's bodies.

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Eventually, they got to a point where the man was able to gently penetrate the woman with a small dilator and then with larger ones, while she concentrated on relaxing.

Finally, they moved on to a situation in which the wife – in the 'female-superior' position – learned to insert her partner further and further into her.

This procedure gave good results (29 cases out of 29 cooperative couples were cured), but they needed motivation. It took at least two weeks of residential therapy.

Incidentally, 16 of the initial 29 women reached orgasm for the very first time by the end of the residential period.

Institute of Psychosexual Medicine therapy

Meanwhile, in the UK a large group of family planning clinic doctors – nearly all of whom were female – were struck by how frequently they were dealing with patients who had vaginismus.

They published various research papers and several books, including: 'Virgin Wives' and 'Contraception & Sexual Life'.

After a while, it became clear to these medics – who included Dr Prudence Tunnadine, Dr Libby Wilson, Dr Fay Hutchinson and many others – that they were in a way replacing the woman's own mother. Indeed, they were in effect giving her 'permission' to relax and enjoy her own vagina.

Again, it's difficult to summarise their treatment in a few lines. But essentially what happens is this.

The woman with vaginismus comes into the clinic and talks about her problem, often with her partner there. It's noteworthy that she may show considerable anger and hostility towards males in general, towards her husband and towards nurses and doctors.

She is eventually persuaded to remove her clothing and to get on the examination couch. Generally, the doctor now gives her a mirror, so that she can view her vulva in it. She may never actually have seen it before, and may sometimes be pleasantly surprised by its appearance.

While encouraging her to relax and to breathe deeply, the doctor gets her to insert her own well-lubricated index finger into the vagina. She is usually astonished to find out how easy this is and how the vagina gradually relaxes and widens around her finger, as the muscular contraction eases up.

If all is going well, the doctor now puts on a glove, lubricates her own finger, and gets the woman to allow the doctor to slip it inside her. This is often referred to as 'the moment of truth' because it is at this point that the patient often reveals her harmful fantasies. For instance, she may blurt out: 'But I though you'd have split me apart by now' or 'I thought I'd be pouring blood or screaming in agony by now'.

The next stage is usually to invite the husband to watch, while the wife demonstrates her newly-learned ability to put a finger inside herself.

After that, if the woman is agreeable, the husband is allowed to place a lubricated finger inside and feel how the vagina widens right out when she relaxes.

When things go really smoothly, it may be possible to get to this point in a single evening. But more often, it's a couple of weeks before the couple start making progress.

But if they're both genuinely keen to make a success of the treatment, it will usually result in a cure. And I can tell you that it's very satisfying to help a couple to defeat this distressing condition and achieve a normal sex life, after years of pain, bitterness and frustration.

Further information: how to get treatment

In Britain, for many years the place to obtain treatment for vaginismus was your local family planning clinic.

Quite a lot of the doctors who worked there had special training in the above-mentioned therapy, and in the 1970s they formed themselves into the Institute of Psychosexual Medicine (IPM).

But currently, family planning clinics are often so overloaded with work that they just can't do this therapy any more.

So, unless there's a hospital near you that provides sex therapy, your best option at the moment is to contact the Institute of Psychosexual Medicine and ask them to put you in touch with one of their members.

An alternative would be to go to either Relate or Relationships Scotland. Their therapists are very well trained, but because they are not medically trained, they will not do a gynaecological examination for you.

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